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# SECTION XIFINANCIAL STATUS1 ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY!2 IF YOUR ANSWER IS "NO" TO THE ABOVE. STATE SOUNCES OF OTHER INCONENot Applicable3 BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS| NAME OF FITUTION                  | ADDRESS (City, Blate, Country)       || --------------------------------- | ------------------------------------ || The Riggs Nat'l Bank, Linclon Br. | 17 & H Street, H.W. Washington, D.C. |4. HAVE YOU EVER BEEN IN, OF PETITIONED FOR, BANKRUPTCY.5. IP YOUR ANSWER IS "YES" TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATEISINA6 GIVE THREE CREDIT HEFERENCES IN THE UNITED STATES| HAME                         | ADDRESS (No., Direct, City, State)  || ---------------------------- | ----------------------------------- || S.W. Rice Co.                | 1342 G. St. N.W., Washington, D.C.  || The. First City Bank & Trust | Fort Bragg, North Carolina          || The Guaranty State Bank      | 1000 Minn Ave., Kansas City, Kansas |7. DO YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT   ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE!8. IF YOUR ANSWER IS "YES" TO THE ABOVE QUESTION, GIVE COMPLETE DETAILSBA9. DO YOU HAVE ANY FINANCIAL INTEREST IN, OR OFFICIAL CONNECTIONS WITH NON-U.S. CORPORATIONS OR DUSINESSES; ON IN   OH WITH U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTSTSECTION XIIMARITAL STATUS1. PRESENT STATUS (Single, Married, Rituwerd, Separated, Divorced, of Annulled) SPELIR MARRIED2 STATE OATE PLACE AND REASON FOR ALL SEPARATICHS DIVORCES OR ANNULMENTSDivorced from Moniqun Pierre Veber, 21 December 1947, Paris, Franca. Divorce ty mutual agreement. Divorced from Carmen 01., 26 Far 1957, Wyandotte County, KansasWIFE, HUSBAND If you have teen married roer than on including annulments use a separate sheet for former wife oz OR FIANCE: husband giving ista required below for all previous marriage if a contemplated, fill in appropriate Informa:: for sunce|         | (First) | (Middle) | (Mordon) | (Last) || ------- | ------- | -------- | -------- | ------ || 1. NAME | Elyette | BROCHOT  | HROCHOT  | CONEIN |4. STATE ANY OTHER NAMES EVER USDNAINDICATE CIRCUMSTANCES (Inchiding length of fiel UNDER WHICH ANY OF THESE NAMES WERE USED. IF LEGAL CHANGE GIVE PARTICULANS fthero and by whel nuthority). USE EXTRA SPACE FROVIDED ON PAGE 10 OF THIS POOM TO RECORD THIS INFORMATION.5. CATE OF MARRIAGE30 March 19506.FACE OF MARPIAGE (City, State, Low)Dillon, South Carolina7. HIS TOP NERI ADORE IS AEROPE MAURIAGE (No, Street, Cur. Stol Comertry)7 rue Docteur Charcot, Champingny sur Harmai, Seire, France|                    |                  || ------------------ | ---------------- || 8. LIVING          | 9. CATE СЯ DEATA ||                    | NA               || 10. CAUSE OF DEATH |                  || NA                 |                  |11. CURRENT ADDRESS (Live dear, if decevered)5011 Hanes Street, clean, Virginia|                   |                                         |                 || ----------------- | --------------------------------------- | --------------- || 12. DATE OF BIRTH | 13. PLACE OF BIRTH (Cor, Share, Conley) | 14. CITIZENSHIP || 4 Sept 1929       | Vinh Vietnam                            | USA             |SECTION AH CONTINUED TO PAGE 10